Translating Initiatives in Depression into Effective Solutions (TIDES) Regional Expansion Project

1. Quality Enhancement Research Initiative Translating Initiatives in Depression into Effective Solutions (TIDES)Regional Expansion Project Lisa Rubenstein, MD, MSPH 9/13/05

2. Mental Illnesses Alcohol and Drug Use Disorders Alzheimer’s Disease and Dementias Musculoskeletal Diseases Respiratory Diseases Cardiovascular Diseases Sense Organ Diseases Injuries (Disabling) Digestive Diseases Communicable Diseases Cancer (Malignant neoplasms) Diabetes Migraine All Other Causes of Disability 0% 4% 8% 12% 16% 20% 24% Impact of Mental Illnesses (of which depression is the most prevalent) Causes of Disability / United States, Canada, and Western Europe, 2000 (WHO)

3. Efficacy Routine Care Effectiveness Quality Improvement

4. Care Model In Place EXPERIMENTAL PATIENTS USUAL CARE PATIENTS BASELINE OUTCOME Is Depression Treatment Efficacious? Patients Randomized Experimental Treatment

5. Depression Efficacy Research • Two types of treatment efficacious in randomized clinical trials • Antidepressants • Short-term, manualized psychotherapy • CBT, IPT • But studies showed low quality of care, variations, disparities

6. Efficacy Routine Care QII Effectiveness Quality Improvement

7. Care Model In Place EXPERIMENTAL PATIENTS USUAL CARE PATIENTS BASELINE OUTCOME Is a Quality Improvement Intervention Effective? POPULATION OF DEPRESSED PATIENTS VISITING STUDY PRACTICE Patients Randomized Researcher- Designed Intervention

8. Effectiveness of QII’s for Depression • Studies randomized at the patient level • Interventions that don’t improve quality • Clinician education • Screening and feedback • Computer reminders • Collaborative care is effective • A multicomponent model • Works for elderly, adolescents, minorities

9. Collaborative Care for Depression Primary Care Nurse Care Manager Patient Mental Health Specialty

10. Efficacy Routine Care Effectiveness Quality Improvement

11. USUAL CARE PATIENTS Is Collaborative Care Cost-Effective When Adopted by Practices? Practices Randomized POPULATION OF DEPRESSED PATIENTS VISITING EXPERIMENTAL PRACTICES Care Model In Place CLINICAL PARTNERS TRAINED TO CARRY OUT THE INTERVENTION EXPERIMENTAL PATIENTS POPULATION OF DEPRESSED PATIENTS VISITING USUAL CARE PRACTICES Researcher- Designed Intervention BASELINE OUTCOME

12. Between Effectiveness and Quality Improvement • Collaborative care is effective and cost-effective • True for large, small, rural, urban, managed care and other types of practices • Researchers developed the tools and trained organizations • Practices implemented the intervention for randomized patients

13. Efficacy Routine Care Effectiveness Quality Improvement

14. Do Outcomes Improve When Practices Design and Implement Improved Depression Care? • If a QI process (e.g., CQI) is convened by researchers, can practices improve? • Without specific attention to the QII evidence base • When effective QII tools, consultation are made available

15. RANDOMLY ASSIGNED PRACTICES EXPERIMENTAL SAMPLE EXPERIMENTAL SAMPLE QI DESIGN PROCESS CARE MODEL START-UP Clinical Partner Intervention USUAL CARE SAMPLE USUAL CARE SAMPLE Researcher Intervention DEPRESSED PATIENT POPULATION VISITING EXPERIMENTAL PRACTICES CARE MODEL IN PLACE DEPRESSED PATIENT POPULATION VISITING USUAL CARE PRACTICES BASELINE OUTCOME BASELINE OUTCOME

16. Quality Improvement Process Success • Can sites design effective depression care improvement? • Using local CQI-- NO • By reviewing and adapting tools and literature on collaborative care-- +

17. Efficacy Routine Care Effectiveness Quality Improvement

18. Can System-Designed Collaborative Care Improve Clinical Outcomes? • Connected to business and strategic plans • Technical and communication assistance still needed • Researcher role envisioned as presaging consultant role

19. POPULATION OF DEPRESSED PATIENTS VISITING EXPERIMENTAL PRACTICES CARE MODEL IN PLACE CONTINUOUS PRE-POST F/U OF PATIENTS RECEIVING INTERVENTION CARE MODEL START-UP QI DESIGN PROCESS QUARTERLY REPORTS Clinical Partner Intervention Researcher Intervention Researcher Support PDSA CYCLES

20. Between Quality Improvement and Routine Care • VA VISN design and implementation • TIDES (intervention) • WAVES (randomized substudy) • COVES (stakeholder cost and value) • CHIACC (informatics) • Can TIDES be spread and sustained? • ReTIDES (regional spread of TIDES)

21. TIDES Short List • Mental Health QUERI: Rick Owen • PI’s: Lisa Rubenstein, Edmund Chaney, JoAnn Kirchner • Investigators: Elizabeth Yano, John Williams, Fen Liu, Mona Ritchie, Susan Vivell, Louise Parker, Laura Bonner, Barbara Simon, Martin Lee • Organizational Leaders: Randy Petzel, Clyde Parkis, Kathy Henderson, Ken Clark, Susan McCutcheon

22. Results for First 600 Patients Depressed Asymptomatic

23. Regional TIDES Expansion (ReTIDES) • Expand TIDES to • Medical centers/practices • One new VISN • Initiate national implementation • Business case • Tools • Connections to appropriate national leadership bodies

24. Top Down, Bottom Up • Top down approach only effective in VA when the bottom up has already been built • Continuous interaction between local and national initiatives • There is no “hand off” from research to a clinical entity

25. VA National Groups Working with TIDES Congress Undersecretary for Health, Veterans Health Administration Seriously Mentally Ill Committee Patient Care Services National Guideline Council National Leadership Council Office of Quality and Performance Nursing Service Office of Care Coordination Employee Education Information Services Mental Health Specialty Primary Care 22 Veterans Integrated Service Networks

26. VISN MAP of TIDES and ReTIDES 2 new VAMC’s (90,000 PC Patients) 9 New VAMC’s (90,000 PC Patients) 2 New VAMC’s (40,000 PC Patients) 2 New VAMC’s (40,000 PC Patients) ReTIDES Spread

27. ReTIDES Evaluation Measures • Semi-structured stakeholder interviews • Clinician web-based survey • System utilization and costs • Performance measure-based evaluation

28. Performance Measure Evaluation • Electronic data only • Includes • HEDIS measures • Fine-tuned measures • Comparison group • Matched practices from a usual care VISN

29. ReTIDES Performance Measure Evaluation Design • Untreated non-equivalent control group design, pretest & postest measures at multiple time intervals O1 02 X 03 04 O1 02 03 04

30. CARE MODEL START-UP QI DESIGN PROCESS Clinical Partner Intervention Researcher Intervention Researcher Support 03 04 PERFORMANCE MEASURES PERFORMANCE MEASURES Experi-mental Care Model In Place 01 02 03 04 Experi-mental Usual Care Usual Care 01 02

31. Threats to Current Design • Performance measures are imprecise relative to the intervention • Positive only if scope and quality of QII are high • Negative if intervention was “good” but too small to affect full practices • Usual threats of non-randomized designs • Mitigated by multiple measures and comparison group

32. Why Better than Randomized for the Purpose? • Previous randomized trials provide a strong evidence base • Low gain of one more randomized trial vs. learning about and fostering system implementation • Randomization is artificial • Constrains naturalistic decision-making

33. Efficacy Routine Care Effectiveness Quality Improvement